Uncovering physical activity trade-offs in transportation policy: A spatial agent-based model of Bogotá, Colombia.

BACKGROUND: Transportation policies can impact health outcomes while simultaneously promoting social equity and environmental sustainability. We developed an agent-based model (ABM) to simulate the impacts of fare subsidies and congestion taxes on commuter decision-making and travel patterns. We report effects on mode share, travel time and transport-related physical activity (PA), including the variability of effects by socioeconomic strata (SES), and the trade-offs that may need to be considered in the implementation of these policies in a context with high levels of necessity-based physical activity. METHODS: The ABM design was informed by local stakeholder engagement. The demographic and spatial characteristics of the in-silico city, and its residents, were informed by local surveys and empirical studies. We used ridership and travel time data from the 2019 Bogotá Household Travel Survey to calibrate and validate the model by SES. We then explored the impacts of fare subsidy and congestion tax policy scenarios. RESULTS: Our model reproduced commuting patterns observed in Bogotá, including substantial necessity-based walking for transportation. At the city-level, congestion taxes fractionally reduced car use, including among mid-to-high SES groups but not among low SES commuters. Neither travel times nor physical activity levels were impacted at the city level or by SES. Comparatively, fare subsidies promoted city-level public transportation (PT) ridership, particularly under a 'free-fare' scenario, largely through reductions in walking trips. 'Free fare' policies also led to a large reduction in very long walking times and an overall reduction in the commuting-based attainment of physical activity guidelines. Differential effects were observed by SES, with free fares promoting PT ridership primarily among low-and-middle SES groups. These shifts to PT reduced median walking times among all SES groups, particularly low-SES groups. Moreover, the proportion of low-to-mid SES commuters meeting weekly physical activity recommendations decreased under the 'freefare' policy, with no change observed among high-SES groups. CONCLUSIONS: Transport policies can differentially impact SES-level disparities in necessity-based walking and travel times. Understanding these impacts is critical in shaping transportation policies that balance the dual aims of reducing SES-level disparities in travel time (and time poverty) and the promotion of choice-based physical activity.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials.

BACKGROUND: Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS: Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS: Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Initial Invasive Versus Conservative Management of Stable Ischemic Heart Disease in Patients With a History of Heart Failure or Left Ventricular Dysfunction: Insights From the ISCHEMIA Trial.

BACKGROUND: Whether an initial invasive strategy in patients with stable ischemic heart disease and at least moderate ischemia improves outcomes in the setting of a history of heart failure (HF) or left ventricular dysfunction (LVD) when ejection fraction is ≥35% but <45% is unknown. METHODS: Among 5179 participants randomized into ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), all of whom had left ventricular ejection fraction (LVEF) ≥35%, we compared cardiovascular outcomes by treatment strategy in participants with a history of HF/LVD at baseline versus those without HF/LVD. Median follow-up was 3.2 years. RESULTS: There were 398 (7.7%) participants with HF/LVD at baseline, of whom 177 had HF/LVEF >45%, 28 HF/LVEF 35% to 45%, and 193 LVEF 35% to 45% but no history of HF. HF/LVD was associated with more comorbidities at baseline, particularly previous myocardial infarction, stroke, and hypertension. Compared with patients without HF/LVD, participants with HF/LVD were more likely to experience a primary outcome composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, HF, or resuscitated cardiac arrest (4-year cumulative incidence rate, 22.7% versus 13.8%; cardiovascular death or myocardial infarction, 19.7% versus 12.3%; and all-cause death or HF, 15.0% versus 6.9%). Participants with HF/LVD randomized to the invasive versus conservative strategy had a lower rate of the primary outcome (17.2% versus 29.3%; difference in 4-year event rate, -12.1% [95% CI, -22.6 to -1.6%]), whereas those without HF/LVD did not (13.0% versus 14.6%; difference in 4-year event rate, -1.6% [95% CI, -3.8% to 0.7%]; P interaction = 0.055). A similar differential effect was seen for the primary outcome, all-cause mortality, and cardiovascular mortality when invasive versus conservative strategy-associated outcomes were analyzed with LVEF as a continuous variable for patients with and without previous HF. CONCLUSIONS: ISCHEMIA participants with stable ischemic heart disease and at least moderate ischemia with a history of HF or LVD were at increased risk for the primary outcome. In the small, high-risk subgroup with HF and LVEF 35% to 45%, an initial invasive approach was associated with better event-free survival. This result should be considered hypothesis-generating. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials.

OBJECTIVES: We conducted a systematic review and network meta-analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. BACKGROUND: Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available. METHODS: We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta-analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques. RESULTS: We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini-crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31-0.55 [all p < .01] and RR 0.42-0.45 [all p < .02], respectively) and with the remaining bifurcation techniques (RR 0.44-0.55 [all p < .05] for DK Crush and RR 0.37-0.45 [all p < .05] for Mini-crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25-4.27 [both p < .05]) and to DK crush (RR 3.02-3.99 [both p < .05]). CONCLUSIONS: DK crush and mini-crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.

Is the built-environment at origin, on route, and at destination associated with bicycle commuting? A gender-informed approach.

There is limited evidence on the gender differences and location-specific built-environment factors associated with bicycling in Latin American cities. This study aimed to assess commuting in Bogotá by (1) analyzing the gender-specific trend of the standardized number of bicycle commuters during 2005-2017; and (2) assessing the socio-demographic, community, built-environment and natural factors associated with bicycle commuting stratified by gender. This secondary-data analysis included data from the Household Travel Surveys and Multipurpose Surveys to calculate the number of bicycle commuters per habitant from 2005 to 2017 by gender. We assessed the socio-demographic and built-environment factors fitting generalized additive models stratified by gender using the 2015 Household Travel Survey. Although both women and men increased the standardized number of bicycle commuters, male commuters show a steeper trend than women, evidencing the widening gender gap in bicycle commuting over time. Bicycle commuting was negatively associated with household motor vehicle ownership, steeper terrain slope, longer commute distance, and scarce low-stress roads at trip origin and route. Among women, the availability of bike paths at the trip destination was positively associated with bicycling, while age and being a student were negatively associated with bicycling. Among men, living in areas with the lowest socio-economic status was positively associated with bicycling, while having a driver's license and living close to bus rapid transit stations were negatively associated with bicycling. In conclusion, bicycle and transport infrastructure play different roles in commuting by bicycle by gender and trip stages (origin - route - destination).

Level of traffic stress-based classification: A clustering approach for Bogotá, Colombia.

The Level of Traffic Stress (LTS) is an indicator that quantifies the stress experienced by a cyclist on the segments of a road network. We propose an LTS-based classification with two components: a clustering component and an interpretative component. Our methodology is comprised of four steps: (i) compilation of a set of variables for road segments, (ii) generation of clusters of segments within a subset of the road network, (iii) classification of all segments of the road network into these clusters using a predictive model, and (iv) assignment of an LTS category to each cluster. At the core of the methodology, we couple a classifier (unsupervised clustering algorithm) with a predictive model (multinomial logistic regression) to make our approach scalable to massive data sets. Our methodology is a useful tool for policy-making, as it identifies suitable areas for interventions; and can estimate their impact on the LTS classification, according to probable changes to the input variables (e.g., traffic density). We applied our methodology on the road network of Bogotá, Colombia, a city with a history of implementing innovative policies to promote biking. To classify road segments, we combined government data with open-access repositories using geographic information systems (GIS). Comparing our LTS classification with city reports, we found that the number of bicyclists' fatal and non-fatal collisions per kilometer is positively correlated with higher LTS. Finally, to support policy making, we developed a web-enabled dashboard to visualize and analyze the LTS classification and its underlying variables.

Utilization of aspirin and statin in management of coronary artery disease in patients with cirrhosis undergoing liver transplant evaluation.

Coronary artery disease (CAD) assessment is a vital part of liver transplantation (LT) evaluation, as it allows for identification and medical optimization prior to transplantation. Although aspirin and statins are standard of care for CAD, they are not universally used in cirrhosis due to concerns about adverse events. Per protocol, coronary angiography was performed as part of the LT evaluation in all patients over the age of 50 years or with CAD risk factors, even if they were younger than 50. Optimal CAD medical management was defined as the use of both statin and aspirin, unless a contraindication was documented. Impact of these medications on hepatic decompensation, renal function, gastrointestinal bleeding, and need for transfusion was evaluated. CAD was detected in 84/228 (36.8%) patients. Lipid profile was similar in patients with and without CAD. In patients with CAD, statins were started in 19 (23%), while aspirin was used in 30 (36%) patients. In patients with obstructive or multivessel CAD, statin therapy was used only in 41% and 65%, respectively. Statins were more likely to be prescribed in patients with diabetes (32% versus 15%, P = 0.05) and history of dyslipidemia (38% versus 15%, P = 0.02). Use of statin therapy was not linked to hepatic decompensation, hospitalization, or rise in Model for End-Stage Liver Disease (MELD). Similarly, use of aspirin therapy was not associated with increased risk acute variceal hemorrhage, gastrointestinal bleeding, or worsening anemia. In conclusion, in decompensated cirrhosis, lipid profile alone is unable to risk stratify patients with CAD. Statin and aspirin appear to be safe. However, they are significantly underutilized for the management of CAD in this patient population. Liver Transplantation 24 872-880 2018 AASLD.

Role of Percutaneous Chronic Total Occlusion Interventions in Patients with Ischemic Cardiomyopathy and Reduced Left Ventricular Ejection Fraction.

PURPOSE OF REVIEW: The purpose of this review is to examine current evidence on the benefit of chronic total occlusion (CTO) revascularization in patients with ischemic cardiomyopathy and propose a systematic approach on how and when to accomplish revascularization in these patients. RECENT FINDINGS: Coronary revascularization in patients with reduced ejection fraction (EF) is advocated for to improve left ventricular function and consequently clinical outcomes. Approximately 16-31% of angiograms in patients with advanced CAD are noted to have a concomitant coronary CTO. Its presence is a main predictor of worse outcomes. Over the past 15 years, advancements in interventional technologies and techniques have made it possible to treat CTO lesions percutaneously with success rates exceeding 90%. Different revascularization techniques have been organized into widely used algorithms for systematic CTO lesion crossing and treatment. Patients with reduced EF can be revascularized percutaneously with goal of complete functional revascularization. However, randomized prospective data is needed to justify the increased patient risks and healthcare costs associated with these procedures.

Should endovascular approach be the first line of treatment for retroperitoneal bleeding with hemodynamic shock following percutaneous intervention? A case series.

OBJECTIVES: To report a series of consecutive patients that developed retroperitoneal hemorrhage (RPH) and persistent hypotension treated with endovascular approach. BACKGROUND: RPH is a rare complication of percutaneous cardiovascular interventions associated with high morbidity and mortality. The standard approach to treat this complication has been a conservative management for stable patients, and urgent vascular surgery for those with persistent hypovolemic shock. Percutaneous endovascular treatment has evolved as an alternative treatment option. METHODS: We implemented a management algorithm for patients with suspected RPH and persistent hypotension which embraced systematic use of emergency endovascular evaluation and treatment following clinical assessment without the use of non-invasive diagnostic testing. We report a series of 8 consecutive patients that developed RPH with persistent hypotension. RESULTS: Successful percutaneous treatment was achieved in all cases with the use of a covered stent. No patient required vascular surgery. The average blood transfusion was 3.4 ± 2.7 units per patient. There were no deaths; one patient experienced acute stent thrombosis that was successfully treated via endovascular approach. At 1-year follow-up, no further events were reported. CONCLUSION: The incorporation of a standardized protocol using only clinical evaluation followed by emergency percutaneous approach without delays attributed to non-invasive diagnostic work-up showed to be feasible and associated with favorable outcomes. © 2016 Wiley Periodicals, Inc.

A head-to-head pharmacodynamic comparison of prasugrel vs. ticagrelor after switching from clopidogrel in patients with coronary artery disease: results of a prospective randomized study.

AIMS: Pharmacodynamic (PD) studies comparing prasugrel and ticagrelor have reached inconsistent findings. Therefore, a comprehensive investigation comparing the PD effects of prasugrel vs. ticagrelor after switching from clopidogrel therapy, exploring both loading dose (LD) and maintenance dose (MD) regimens represented the aim of this study. METHODS AND RESULTS: Patients (n = 110) with coronary artery disease were randomized to prasugrel (60 mg LD/10 mg MD q.d.) or ticagrelor (180 mg LD/90 mg MD b.i.d) therapy for 1 week. Pharmacodynamic assessments were conducted using three assays (vasodilator-stimulated phosphoprotein, VerifyNow P2Y12, and light transmittance aggregometry, LTA) at baseline, 30 min, 2, 24 h, and 1 week. The impact of initiating ticagrelor MD 12 vs. 24 h after LD administration was also assessed. Switching clopidogrel-treated patients to an LD of prasugrel or ticagrelor was associated with a reduction in platelet reactivity at 30 min and was sustained at all time points up to 1 week with the MD (P < 0.001 for all assays). Platelet reactivity was similar with prasugrel and ticagrelor with all assays at 30 min, 2 h, and 1 week (P > 0.05 for all time points), with the exception of LTA at 30 min (lower with prasugrel; P = 0.003). At 24 h, platelet reactivity was lower among patients initiating ticagrelor MD after 12 vs. 24 h post-LD. Rates of high platelet reactivity (HPR) were markedly reduced and similar between groups. CONCLUSION: Prasugrel and ticagrelor exert similar levels of P2Y12 inhibition achieving more potent PD effects and reduced HPR rates compared with clopidogrel which are reached promptly following LD and sustained with MD. CLINICALTRIALSGOV IDENTIFIER: NCT01852175.

Candidates for transcatheter aortic valve replacement: fitting the PARTNERS criteria.

OBJECTIVES: To determine an estimate patient volume with severe AS meeting PARTNER-B criteria, with the objective of providing insights into the annual volume needed to sustain a TAVR program. BACKGROUND: While the prevalence of AS is well documented, potential TAVR candidates remains less established. A better understanding of this population is critical for the development of TAVR programs. Though no clear volume has been determined, societies suggest a minimum of 20-24 annual cases to establish a TAVR program. METHODS: A total of 21,652 patients were screened from a single center echocardiography registry over a 3-year period. From them, 833 patients with AS were identified representing our study population. Severity was stratified by echocardiographic criteria. Those identified to have moderate-to-severe and severe AS were further investigated to determine clinical status and surgical candidacy. Nonsurgical candidates were cross referenced with the PARTNER-B exclusion criteria to determine eligibility for TAVR. RESULTS: Symptomatic AS was present in 133 patients (16%). Fifty (38%) were considered nonsurgical candidates. Nonsurgical patients had higher STS score (11.1 ± 10.8 vs. 4.0 ± 3.3, P < 0.001). After applying PARTNERS-B exclusion criteria, only 18 patients (14%) were considered TAVR candidates. These findings indicate that to meet the recommended annual volume of 20-24 TAVR cases, a minimum of 150-170 symptomatic severe AS patients are required. CONCLUSION: In real world clinical practice, the prevalence of AS meeting PARTNERS-B criteria for TAVR can be low. These findings suggest that either high volume valvular centers or regional referral centers will need to be considered as part of the strategy to incorporate this new technology into clinical practice.

Impact of renal function on clopidogrel-induced antiplatelet effects in coronary artery disease patients without diabetes mellitus.

Diabetes mellitus (DM) is the most important predictor of chronic kidney disease (CKD), and pharmacodynamic (PD) studies have shown that DM patients with impaired renal function are characterized by reduced clopidogrel response. However, post-hoc PD studies conducted in unselected cohorts, composed of both DM and non-DM patients, have reached controversial findings on the effects of CKD on clopidogrel response, likely attributed to patient heterogeneity. The impact of renal function on clopidogrel response in non-DM patients remains unexplored and represented the aim of this prospective investigation. We conducted a prospective PD investigation in non-DM patients with and without CKD defined as an estimated glomerular filtration rate (eGFR) below or above 60 mL/min, respectively. All patients had known coronary artery disease and were on maintenance aspirin therapy. PD assessments were assessed at baseline and 2 and 24 h after a 600 mg loading dose of clopidogrel. PD assays included light transmission aggregometry (LTA) using 5 and 20 µmol ADP with and without PGE1 and flow cytometric assessment of the phosphorylation status of the vasodilator-stimulated phosphoprotein (VASP) to determine the platelet reactivity index. A total of 60 patients were studied (n = 30 eGFR ≥60 mL/min; n = 30 eGFR <60 mL/min). At baseline there were no differences between groups. Following clopidogrel loading dose administration, levels of on-treatment platelet reactivity were similar between groups at 2 and 24 h as measured with LTA and VASP. Accordingly, there were no differences in rates of high on-treatment platelet reactivity between groups. In non-DM patients with CAD, the presence of impaired renal function is not associated with differences in clopidogrel-induced antiplatelet effects compared with patients with preserved renal function.

Effects of cangrelor in coronary artery disease patients with and without diabetes mellitus: an in vitro pharmacodynamic investigation.

Platelets from patients with diabetes mellitus (DM) are hyper-reactive and whether cangrelor, a potent intravenous P2Y(12) receptor blocker, has differential pharmacodynamic (PD) effects according DM status is unknown. The aim of this investigation was to evaluate the in vitro PD effects of cangrelor in coronary artery disease (CAD) patients with and without DM. This prospective study enrolled 120 clopidogrel-naïve patients with CAD on aspirin therapy. PD assessments using cangrelor (500 nmol/l) in vitro included vasodilator-stimulated phosphoprotein assay to obtain the P2Y(12) reactivity index (PRI), and multiple electrode aggregometry (MEA). In a 20 patients subgroup, dose-dependent response was assessed following exposure to escalating concentrations (baseline, 5, 50, 500 and 5,000 nmol/l); thrombin generation processes were evaluated by thromboelastography (TEG). PD data were evaluable in 103 patients. No differences in baseline PD parameters were observed in DM (n = 48) and non-DM (n = 45) subjects. Cangrelor reduced PRI values irrespective of DM status (p < 0.0001), yielding no difference in patients with and without DM (16.1 ± 12.3 vs. 16.8 ± 11.3; p = 0.346). All MEA values were significantly reduced, although this was of greater magnitude with purinergic compared to non-purinergic agonists. A trend analysis showed a dose-dependent effect on platelet inhibition, with no interaction due to DM status, whereas no significant dose-dependent effect was observed for TEG-derived parameters. Therefore, in vitro cangrelor provides potent and dose-dependent blockade of the platelet P2Y(12) receptor, with no differential effect in DM and non-DM patients. In addition, in vitro cangrelor exerts moderate inhibitory effects on non-purinergic platelet signaling pathways, without modulating platelet-derived thrombin generation processes.

User expectations and perceptions towards new public transport infrastructure: evaluating a cable car in Bogotá.

Cable cars are a viable alternative to improve citizens' accessibility in zones with limitations on urban public transport supply due to the topography. In Latin America, such systems have recently been implemented in zones with high levels of poverty and vulnerability. Although the social implications of their implementation are relevant, individual expectations of these systems and how current changes in travel conditions and quality of life are perceived have not been widely reported in the literature. This paper aims to evaluate users' expectations and perceptions of a new cable car in the southern periphery of Bogotá (Colombia). We conducted a panel survey before (n = 341) and after (n = 301) the cable car started operations to evaluate the ranking of preferences toward a set of possible benefits of the project. We estimated discrete choice models to analyze the statistical differences between the expectations and perceptions before and after changes. Results suggest that travel time reductions, comfort improvements, and in-vehicle security are the benefits most valued by the users. Even though the project meets expectations of these aspects, it seems to fall short in expectations of reductions of pollution. Individuals' experience with the cable car shapes their perceptions of the system. We found that perceptions differ between those who have used the service at least once and those who never did. Policy implications derived from this study might be of interest to decision-makers seeking to guarantee the public acceptability of urban projects.

Commuter's personal exposure to air pollutants after the implementation of a cable car for public transport: Results of the natural experiment TrUST.

Commuters in urban settlements are frequently exposed to high concentrations of air pollutants due to their proximity to mobile sources, making exposure to traffic-related air pollutants an important public health issue. Recent trends in urban transport towards zero- and low-tailpipe emission alternatives will likely result in decreased exposure to air pollutants. The TrUST (Urban transformations and health) study offers a unique opportunity to understand the impacts of a new cable car (TransMiCable) in underserved communities within Bogotá, Colombia. The aims of this study are to assess the personal exposure to fine particulate matter (PM2.5), equivalent Black Carbon (eBC), and Carbon Monoxide (CO) in transport micro-environments and to estimate the inhaled dose per trip during mandatory multimodal trips before and after the implementation of the TransMiCable. We collected personal exposure data for Bus-Rapid-Transit (BRT) feeder buses, regular buses, informal transport, pedestrians, and TransMiCable. TransMiCable showed lower exposure concentration compared to BRT feeder and regular buses (PM2.5: 23.6 vs. 87.0 µg m-3 (P ≤ 0.001) and eBC: 5.2 vs. 28.2 µg m-3 (P ≤ 0.001), respectively). The mean concentration of PM2.5 and eBC inside the TransMiCable cabins were 62 % and 82 % lower than the mean concentrations in buses. Furthermore, using a Monte Carlo simulation model, we found that including the TransMiCable as a feeder is related to a 54.4 µg/trip reduction in PM2.5 inhaled dose and 35.8 µg/trip in eBC per trip. Those changes represent a 27 % and 34 % reduction in an inhaled dose per trip, respectively. Our results show that PM2.5, eBC, and CO inhaled dose for TransMiCable users is reduced due to lower exposure concentration inside its cabins and shorter travel time. The implementation of a cable car in Bogotá is likely to reduce air pollution exposure in transport micro-environments used by vulnerable populations living in semi-informal settlements.

Effects of an urban cable car intervention on physical activity: the TrUST natural experiment in Bogotá, Colombia.

BACKGROUND: Cable cars are part of the transport system in several cities in Latin America, but no evaluations of their effects on physical activity are available. TransMiCable is the first cable car in Bogotá, Colombia, and the wider intervention includes renovated parks and playgrounds. We assessed the effects of TransMiCable and the wider intervention on physical activity. METHODS: The Urban Transformations and Health natural experiment was a prospective quasi-experimental study conducted from Feb 1, 2018, to Dec 18, 2018 (baseline, pre-intervention) and from July 2, 2019, to March 15, 2020 (post-intervention follow-up) in the TransMiCable intervention area (Ciudad Bolívar settlement) and a control area without TransMiCable (San Cristóbal settlement). A multistage strategy was used to sample households in each area, with one adult (aged ≥18 years) per household invited to participate. Eligible participants had lived in the intervention or control areas for at least 2 years and were not planning to move within the next 2 years. Physical activity was assessed among participants in the intervention and control areas before and after the inauguration of TransMiCable in Ciudad Bolívar with the International Physical Activity Questionnaire (long form) and with wearable accelerometers. Complete cases (those with baseline and follow-up data) were included in analyses. Respondents were classed as being physically active if they met 2020 WHO guidelines (≥150 min per week of moderate activity, ≥75 min per week of vigorous activity, or equivalent combinations); and accelerometery data were classified with the Freedson cut-points for adults. Data were also gathered in zonal parks (area ≥10 000 m2) and neighbourhood parks (area <10 000 m2) in the intervention and control areas by direct observation with the System for Observing Play and Recreation in Communities, to assess levels of physical activity before and after the TransMiCable intervention. Multilevel regression models were used to assess changes in physical activity associated with the TransMiCable intervention. FINDINGS: Physical activity questionnaires were completed by 2052 adult participants (1289 [62·8%] women and 763 [37·2%] men; mean age 43·5 years [SD 17·7]) before the inauguration of TransMiCable. After the inauguration, the follow-up (final) questionnaire sample comprised 825 adults in the intervention group and 854 in the control group, including 357 adults in the intervention group and 334 in the control group with valid accelerometery data. 334 (40·5%) of 825 participants in the intervention group reported levels of physical activity that met the 2020 WHO guidelines during walking for transport before the intervention, and 426 (51·6%) afterwards (change 11·1 percentage points [95% CI 6·4 to 15·9]). A similar change was observed in the control group (change 8·0 percentage points [3·4 to 12·5]; adjusted odds ratio [OR] for the time-by-group interaction, intervention vs control group: 1·1 [95% CI 0·8 to 1·5], p=0·38). Time spent doing moderate-to-vigorous physical activity, measured with accelerometers, did not change in the intervention group after the inauguration of TransMiCable (change -0·8 min per day [-4·6 to 3·0]) and did not change compared with the control group (adjusted ß for the time-by-group interaction: 1·4 min per day [95% CI -2·0 to 4·9], p=0·41). Moderate-to-vigorous physical activity was 52·1 min per day (SD 24·7) before and 59·4 min per day (35·2) after the inauguration of TransMiCable in new regular users who reported using TransMiCable during mandatory trips for work or education (n=32; change 7·3 min per day [-22·5 to 7·9]). After the intervention, an increase in the proportion of male individuals engaging in moderate or vigorous physical activity was observed in a renovated zonal park (adjusted OR for the time-by-group interaction, intervention vs control park: 2·7 [1·1 to 6·8], p=0·033). Female users of a renovated neighbourhood park were less likely to become engaged in moderate or vigorous physical activity than female users of the control area neighbourhood park (adjusted OR for the time-by-group interaction: 0·4 [0·1 to 0·6], p=0·019). INTERPRETATION: It is encouraging that walking for transport remained high in the TransMiCable intervention area when the use of private motorised transport had increased elsewhere in Bogotá. In low-income urban areas, where transport-related walking is a necessity, transport interventions should be focused on efforts to maintain participation in active travel while improving conditions under which it occurs. FUNDING: Wellcome Trust (as part of the Urban Health in Latin America project); Bogotá Urban Planning Department; Ministry of Science, Technology, and Innovation of Colombia; Universidad de Los Andes; Fundación Santa Fe de Bogotá; and Universidad del Norte. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Slow-release microencapsulates containing nanoliposomes for bioremediation of soil hydrocarbons contaminated.

Encapsulation and nutrient addition in bacterial formulations have disadvantages concerning cell viability during release, storage, and under field conditions. Then, the objective of this work was to encapsulate a bacterial consortium with hydrocarbon-degrading capacities in different matrices composed of cross-linked alginate/ polyvinyl alcohol /halloysite beads (M1, M2, and M3) containing nanoliposomes loaded with or without nutrients and evaluate their viability and release in a liquid medium, and soil (microcosmos). Also, evaluate their capacity to remove total petroleum hydrocarbons (TPH) for 165 days and matrices characterization. The encapsulate consortium showed a quick adaptation to contaminated soil and a percentage of removal (PR) of TPH up to 30% after seven days. All the matrices displayed a PR of up to 90% after 165 days. The matrix M2 displayed significant resistance to degradation and higher cell viability with a PR of 94%. This result supports the encapsulation of bacteria in a sustainable matrix supplemented with nutrients as a well-looked strategy for improving viability and survival and, therefore, enhancing their effectiveness in the remediation of hydrocarbon-contaminated soils.

Radial Artery Access Complications: Prevention, Diagnosis and Management.

The transradial approach for cardiac catheterization, coronary angiography, and percutaneous intervention is associated with a lower risk of access site-related complications compared to the transfemoral approach. However, with increasing utilization of transradial access for not only coronary procedures but also peripheral vascular procedures, healthcare personnel are more likely to encounter radial access site complications, which can be associated with morbidity and mortality. There is significant heterogeneity in the reporting of incidence, manifestations, and management of radial access site complications, at least partly due to vague presentation and under-diagnosis. Therefore, physicians performing procedures via transradial access should be aware of possible complications and remain vigilant to prevent their occurrence. Intraprocedural complications of transradial access procedures, which include spasm, catheter kinking, and arterial dissection or perforation, may lead to patient discomfort, increased procedure time, and a higher rate of access site cross over. Post-procedural complications such as radial artery occlusion, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve injury could lead to patient discomfort and limb dysfunction. When radial access site complications occur, comprehensive evaluation and prompt treatment is necessary to reduce long-term consequences. In this report, we review the incidence, clinical factors, and management strategies for radial access site complications associated with cardiac catheterization.

Comparing COVID-19 in the antipodes: Insights from pandemic containment strategies on both sides of the Pacific.

That the COVID-19 pandemic is unprecedented in terms of its scale, spread and shocks can be evinced by the myriad of ever-changing responses cities all around the world have rolled out throughout the different waves of outbreaks. Although the threat is similar across the world, it took some time before its reach became global and the waves of outbreak are experienced by cities at different times. While this staggered spread imply that some cities might manage the virus better as they learn from the experiences of cities which had been amongst the earliest to face the virus, the reality is more complicated. In the early stages of the pandemic, the global consensus on the best way to contain the virus swiftly converged in the interlinked strategies of restricting the movement of people and minimizing their social contact. However, the effectiveness of these strategies differ greatly between cities. To that end, this study focuses on COVID-19 responses in two regions (Latin America and Southeast Asia) and examines the evolution of the first wave of COVID-19 outbreaks during 2020 in Singapore, Jakarta (Indonesia), Bogotá (Colombia) and Santiago (Chile). The study is based on a comparative approach and uses a variety of data sources, namely morphology, density, housing concentration, mobility, and governance in the four analyzed cities. The goal is to shed light on the response of city governments in these two different regions in terms of mobility restrictions in order to reduce the cases of new infections. The results show the relevance of urban policies and their territorial approaches, particularly in terms of mobility and public transport networks in the four cities.

The path towards herd immunity: Predicting COVID-19 vaccination uptake through results from a stated choice study across six continents.

Despite unprecedented progress in developing COVID-19 vaccines, global vaccination levels needed to reach herd immunity remain a distant target, while new variants keep emerging. Obtaining near universal vaccine uptake relies on understanding and addressing vaccine resistance. Simple questions about vaccine acceptance however ignore that the vaccines being offered vary across countries and even population subgroups, and differ in terms of efficacy and side effects. By using advanced discrete choice models estimated on stated choice data collected in 18 countries/territories across six continents, we show a substantial influence of vaccine characteristics. Uptake increases if more efficacious vaccines (95% vs 60%) are offered (mean across study areas = 3.9%, range of 0.6%-8.1%) or if vaccines offer at least 12 months of protection (mean across study areas = 2.4%, range of 0.2%-5.8%), while an increase in severe side effects (from 0.001% to 0.01%) leads to reduced uptake (mean = -1.3%, range of -0.2% to -3.9%). Additionally, a large share of individuals (mean = 55.2%, range of 28%-75.8%) would delay vaccination by 3 months to obtain a more efficacious (95% vs 60%) vaccine, where this increases further if the low efficacy vaccine has a higher risk (0.01% instead of 0.001%) of severe side effects (mean = 65.9%, range of 41.4%-86.5%). Our work highlights that careful consideration of which vaccines to offer can be beneficial. In support of this, we provide an interactive tool to predict uptake in a country as a function of the vaccines being deployed, and also depending on the levels of infectiousness and severity of circulating variants of COVID-19.